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Abstract

Background

The engagement of hospitals in Public-Private Mix (PPM) for Directly Observed Treatment
Short-Course (DOTS) strategy has increased rapidly internationally - including in
Indonesia. In view of the rapid global scaling-up of hospital engagement, we aimed
to estimate the proportion of outpatient adult Tuberculosis patients who received
standardized diagnosis and treatment at outpatients units of hospitals involved in
the PPM-DOTS strategy.

Methods

A cross-sectional study using morbidity reports for outpatients, laboratory registers
and Tuberculosis patient registers from 1 January 2005 to 31 December 2005. By quota
sampling, 62 hospitals were selected. Post-stratification analysis was conducted to
estimate the proportion of Tuberculosis cases receiving standardized management according
to the DOTS strategy.

Result

Nineteen to 53% of Tuberculosis cases and 4-18% of sputum smear positive Tuberculosis
cases in hospitals that participated in the PPM-DOTS strategy were not treated with
standardized diagnosis and treatment as in DOTS.

Conclusion

This study found that a substantial proportion of TB patients cared for at PPM-DOTS
hospitals are not managed under the DOTS strategy. This represents a missed opportunity
for standardized diagnoses and treatment. A combination of strong individual commitment
of health professionals, organizational supports, leadership, and relevant policy
in hospital and National Tuberculosis Programme may be required to strengthen DOTS
implementation in hospitals.

Background

The World Health Organization (WHO) has promoted the Directly Observed Treatment Short-Course
(DOTS) strategy at the international level since the mid-1990s, and it has proved
a cost-effective strategy to combat Tuberculosis (TB) [1-3]. DOTS strategy consists of five strategic pillars:

However, the implementation of DOTS strategy by public health facilities is insufficient
to ensure the notification of all TB cases in the community as well as to provide
adequate treatment and prevent further transmission [5,6].

Tuberculosis (TB) patients can receive care from a wide array of services, such as
community health centres, general practitioners, traditional healers, chest clinics,
and hospitals [7-11]. These facilities, however, do not necessarily implement the internationally-recommended
DOTS strategy nor link to the National TB Programme. Evidence shows that without proper
linkage to National TB Programme, these facilities are in fact providing poor quality
diagnoses and treatment [12-15]. The need to engage different care providers in providing TB services is therefore
urgent and the Public-Private Mix (PPM) for the DOTS initiative by WHO has been launched
in response to this challenge [10,16].

Hospitals in particular play a major role as a source of TB treatment in many high-burden
countries [11,17,18]; thus hospitals have been identified as priority targets for PPM-DOTS initiatives.
Public-general and medical-college hospitals are the two types of health care providers
most engaged in PPM-DOTS schemes [19]. Improved case detection and treatment outcome has been noted in several countries
as the result of involving hospitals in PPM-DOTS strategy [19-22]. This favourable outcome has led to rapid scaling-up of hospital involvement. The
number of high-burden countries adopting the hospital PPM-DOTS approach at the national
level increased rapidly from 4 to 14 countries during 2005-2007 [19]; Indonesia is no exception, with an increase from 31% in 2005 (two years after the
scaling up) to 37% of hospitals involved in PPM-DOTS by early 2007 (Unpublished data
from Ministry of Health Republic of Indonesia).

Several publications have raised concerns regarding the quality of DOTS strategy implementation
in hospitals [17,18,23-25]. Poor compliance with diagnostic and treatment guidelines, and the increase of Multi-Drug-Resistant-TB,
further raises concerns about quality [18,24]. In view of the rapid global scaling-up of hospital engagement, we aimed to analyse
the access to DOTS based services in hospitals already involved in PPM-DOTS strategy
in Indonesia by determining the proportion of outpatient adult TB patients who actually
received standardized diagnosis and treatment.

Methods

Study design

This was a cross-sectional study that was part of a larger research entitled: Assessment
of the implementation of DOTS strategy in hospitals in six provinces on Java Island,
Indonesia. The study was conducted from August 2006 to July 2007, with a pilot-study
organized in three hospitals located in two provinces (Central Java and Yogyakarta).

Figure 1 describes the flow of patients and information about TB patients in hospitals. Depending
on the main symptoms, TB suspects may have different entrances when using the outpatient
service. They may visit general outpatient service or more specialized outpatient
units (such as pulmonary, internal medicine, neurology, and surgery) prior to visiting
a specially designated DOTS unit. To confirm the diagnosis, ideally a sputum smear
examination should first be carried out and the results recorded in the laboratory
register [26]. A certain proportion of TB suspects may also have to undertake other diagnostic
tests simultaneously, most commonly a chest X-ray [17,18,27]. After completing the diagnostic tests, TB suspects return to the outpatient unit
they initially visited. The diagnosis is recorded in the medical record, and later
sent to the medical record department for the purpose of coding using the International
Classification of Diseases (ICD) system. TB diagnoses are coded as ICD X A.15-A.19.
However, it has been observed that the majority of hospitals do not record the specific
ICD code but merge into a group of ICD codes for Tuberculosis. Based on the medical
records, the hospital produces quarterly morbidity reports, including TB.

Figure 1.Flow of patients and information among Tuberculosis cases in PPM-DOTS hospitals.

For treatment of TB patients, there are three possible scenarios. First, not all TB
patients are managed in an outpatient unit with proper diagnosis and close monitoring
of treatment using standardized TB patient register as in the DOTS strategy. Secondly,
TB patients are treated with DOTS strategy in the unit where the patients were originally
diagnosed or in the hospital DOTS unit (if available). Finally, confirmed TB patients
are referred to other DOTS facilities closer to the patients' homes (such as to a
community health centre). Due to incomplete recording of TB referrals from hospitals
to other DOTS facilities, this study used the assumption of the referral rate from
a study in Yogyakarta [22]. The median referral rate among hospitals during 2003-2005 was 31.5% for all TB cases
and 32.6% for sputum smear positive TB cases [22].

For those treated with DOTS strategy, the TB patient registers are then sent to the
TB supervisor at the District Health Office and the information is further aggregated
at the province and national levels.

Data collection

Trained surveyors collected the morbidity reports, laboratory registers and TB patient
registers from the hospitals. Data from registers were double-entered. In order to
improve the validity of data, the trained surveyors contacted the medical record staff
to guarantee the completeness of the data and to clarify any issues arising.

Study population, sampling strategy and sample

The study population included hospitals participating in PPM-DOTS strategy based on
2006 data from the National TB Programme in Indonesia. It consisted of 72 public general
hospitals, 70 private general hospitals, and 8 pulmonary hospitals in Java Island,
Indonesia. Providers from all these hospitals had taken part in standardized DOTS
training activities conducted by the National TB Programme.

The sampling for the larger study was carried out using quota sampling. The quota
was determined by consideration of the proportion, type, and ownership of PPM-DOTS
hospitals among Java Island provinces. Based on type and ownership, the hospitals
were differentiated into public general hospitals, private general hospitals, and
public pulmonary hospitals. For this paper, we included hospitals in the study population
which had been involved in PPM-DOTS for at least two years prior to 2006, and which
had both a TB recording and reporting system and an outpatient-morbidity report system
in place. Sixty-two hospitals met the inclusion criteria.

Analyses

The analyses included, firstly, demographic characteristics of TB cases for each hospital
group and evaluation of the differences by Kruskall Wallis tests and, secondly, post-stratification
analysis to estimate the proportion of TB cases not treated under a DOTS unit. Post-stratification
analysis estimated the weighted cumulative number of TB cases in the morbidity report
and patient register as well as cases who were sputum smear-positive in the laboratory
and TB registers. To calculate the post-stratification weight, the number of hospitals
in the study population was divided by the number of sampled hospitals. The weighted
cumulative number of TB cases was then estimated by multiplying the post-stratification
weight by the cumulative number of estimated TB cases in the sample.

Ethics

Approval for the study's ethics was received from Universitas Gadjah Mada, Indonesia.
Permission for accessing the hospital registers was obtained from the local governments
and hospitals. Patient confidentiality was assured during data analyses and presentation
of study findings. The findings were shared with the hospitals, District-Provincial
Health Offices and the National TB Programme.

Results

The numbers of hospitals sampled were: 31 public general hospitals, 29 private general
hospitals, and 2 pulmonary hospitals. All included hospitals have access to the National
TB Programme guidelines and manual. Nevertheless, this does not mean that the hospitals
have already integrated the National TB Programme guidelines into their standard operating
procedure for TB patients seeking care at the hospital (Table 1). Not all hospitals have a formal Memorandum of Understanding for the implementation
of the DOTS strategy.

The number of TB cases from the morbidity reports, laboratory registers and TB patient
registers had a skewed distribution. In general, public pulmonary hospitals registered
a higher number of TB cases per hospital compared to general hospitals. The medians
were 712 in pulmonary hospitals, 247 in public general hospitals and 102 in private
general hospitals (p = 0.03) (Table 2). Furthermore, the total number of TB cases (n = 349) registered in pulmonary hospital
DOTS units was higher than in public (n = 52) or private (n = 19) general hospitals
(p = 0.01). Similarly, the number of sputum smear positive TB cases identified by
the pulmonary hospital laboratories (n = 198) was greater than in public (n = 43)
or private (n = 17) general hospitals (p = 0.001). A similar pattern was found for
the number of sputum smear positive TB cases undergoing treatment at DOTS units (p
= 0.004).

Table 2. Number of Tuberculosis cases: comparison of morbidity reports, laboratory registers
and TB patient registers at general hospitals and pulmonary hospitals, 2005.

Results of the post-stratification analysis showed the discrepancy between the number
of TB cases recorded in the TB patient register and those in the hospital morbidity
report. After adjusting for the referral rate, the proportion of TB cases not recorded
in TB patient register was 53% (in public general hospitals) and 52% (in private general
hospitals). This proportion was larger in general hospitals than that in public pulmonary
hospitals (i.e. 19.5%) (Table 3).

After considering the referral rate, the gap between the number of sputum smear positive
TB cases recorded in the laboratory register and those recorded in the TB patient
register ranged from 4% to 18%. The highest proportion was in public general hospitals,
followed by public pulmonary hospital and private general hospitals (18.2%, 8.1%,
and 4.2% respectively) (Table 3).

Discussion

The findings show sub-optimal access to the DOTS strategy among TB patients in hospitals
involved in the PPM-DOTS initiative. This inconsistent access to DOTS strategy is
more prominent in public general hospital whereas the general and medical college
hospitals are the most common type of hospitals involved in PPM-DOTS [19]. A similar phenomenon was also reported in a study by Loveday et al. (2008), which found that 58% of smear positive TB cases did not access standardized
National TB Programme treatment in the hospitals [18]; this could be due to a lack of cooperation in the application of diagnosis and treatment
based on DOTS strategy for all TB patients [15,28], perceived complexity of DOTS based diagnosis and treatment [29], and perceived low quality of services due to provision of free TB drugs [29].

Taking into account the reliance on secondary data in this study, the findings still
raise the issue of missed opportunity for PPM-DOTS hospitals to deliver quality diagnosis
and treatment for all TB suspects. This could lead to misdiagnosis of TB patients
and, consequently, improper treatment of TB patients. With the present, and alarming,
problem of multiple-drug-resistant TB [18,24], low quality of TB case management in hospitals implementing PPM-DOTS strategy certainly
requires urgent attention. Therefore, we argue that a better balance is required between
the expansion of PPM-DOTS strategy to new hospitals, and improvement of quality DOTS
strategy implementation in existing hospitals.

Since services for TB patients can be delivered at several outpatient units in collaboration
with other units (DOTS units, laboratories, medical records units, etc), the findings
also reflected the complexity of internal linkages between those different micro systems
involved in delivering TB care in hospitals. Several factors may contribute to the
weakening of internal linkages, i.e. from micro system to organization level, up to
the policy at the national level. At the micro system level, individual commitment
of health professionals [25], as well as teamwork, information, performance and improvement, and clinical leadership
[30] are key factors. Subsequently, hospital and National Tuberculosis Programme policies
that help to support and strengthen those factors (in order to improve quality) are
critical.

Different mechanisms exist to enhance the quality of DOTS strategy implementation
in hospitals. At the micro system level, launching of the International Standard for
TB Care can be an initial bridge for improving the commitment of health professionals
involved in delivering TB care [31,32]. Endorsement from professional organizations and operational support to ensure implementation
of the International Standard for TB Care among specialists are required [33]. Staff incentives are important to focus the staff on providing high quality services
to patients [30]. However, there is limited evidence of the types of incentives that are effective
in the context of PPM-TB control [34,35]. At the hospital level, Siddiqi et al. (2008) implemented TB clinical audit as a process measurement for improving clinical
TB care [36]. Experience in the Philippines suggests that national level regulations such as accreditation
and certification of PPM-DOTS hospitals can also be effective in improving the quality
of TB services [34]. Finally, existing mechanisms in TB control management, i.e. internal and external
supervision, should also be strengthened to improve practices in the context of PPM-DOTS
hospitals.

This study is limited to measure, not explain, the phenomenon of missed opportunities
on TB diagnosis and treatment in PPM-DOTS hospitals. The assumed referral rate for
sputum smear positive TB cases may be considered too high for Java Island and other
areas in Indonesia because the rates were calculated under a closely monitored pilot
project. If this is the case, our results in fact underestimate the proportion of
cases not administered under DOTS strategy.

Conclusions

This study found that a substantial proportion of TB patients cared for at PPM-DOTS
hospitals are not managed under the DOTS strategy. This represents a missed opportunity
for standardized diagnoses and treatment. A combination of strong individual commitment
of health professionals, organizational supports, leadership, and relevant policy
in hospital and National Tuberculosis Programme may be required to strengthen DOTS
implementation in hospitals.

Authors' contributions

AP was responsible for developing the research idea, designing the study, executing
the data collection, analysis and interpretation of the results, as well as for the
writing of the manuscript. LL and HS contributed to the interpretation of the data,
and revision of the manuscript. AU participated in the study design, execution of
the data collection, analysis and interpretation of the data, as well as in substantially
revising the manuscript. AK gave intellectual inputs to the study design, analysis
and interpretation of data and performed the critical revision of the manuscript.
AU and AK made equal contribution to the study. All authors read and approved the
final manuscript.

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

The researchers gratefully acknowledge the assistance of the participating hospitals.
We also acknowledge Hari Agus Sanjoto and Mohammad Arifin for their contribution to
data collection and data entry. This research was supported by the Sub-Directorate
of Tuberculosis, Ministry of Health, Republic of Indonesia and funded by DFID-UK through
the World Health Organization (Project: INO TUB 002 XW 06 EC0. P01. A01) and the Centre
for Global Health at Umeå University (supported by FAS, the Swedish Council for Working
Life and Social Research, grant no 2006-1512).